System and methods for providing medication selection guidance

ABSTRACT

A system and associated methods provide medication selection guidance at the time of a prescription event for a given patient, or at other times, such as when changes occur in the patient&#39;s healthcare plan coverage. In one medication selection guidance method, information is received regarding a clinician-preferred medication prescription related to a selected patient, and based on at least one record of the selected patient, a specific information set is retrieved. For instance, the specific information set may include medications the patient is currently taken, healthcare plan coverage for the patient, or other types of information. Then, other medications that can be prescribed to the patient as alternatives to the clinician-preferred medication prescription may be determined based on the specific information set. These alternative medications may be evaluated against the patient&#39;s healthcare plan coverage to present available medication options and associated out-of-pocket costs to the patient.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a divisional of U.S. patent application Ser. No.11/319,797 filed Dec. 28, 2005, entitled “System and Methods forProviding Medication Selection Guidance” (Attorney Docket No.CRNI.117423) and claims priority to commonly owned U.S. ProvisionalApplication Ser. No. 60/640,028, filed Dec. 29, 2004, of which eachapplication is assigned or under obligation of assignment to the sameentity application and both of which are incorporated in thisapplication by reference.

STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT

Not Applicable.

BACKGROUND

The present invention relates generally to the field of computersoftware. More particularly, the present invention relates to acomputerized system and methods for providing guidance of medicationselection.

Clinicians have traditionally made decisions regarding which medicationto prescribe for a patient's health condition or illness based onmedication information that they have memorized or can quickly look upin a reference guide. The clinician may have learned about a given kindof medication (as an example, a specific anti-inflammatory) from amedical journal, advertisement, educational lecture, or other means.However, clinicians rarely have the time or resources to compare aspecific medication with all other medications that provide a similartherapeutic effect and have an acceptable level of efficacy. It may bethat medications other than the medication chosen by the clinician canprovide the therapeutic benefit that the clinician had intended whilebetter meeting a particular patient's needs. For instance, the chosenmedication may not be covered by the patient's healthcare insuranceplan, or may otherwise require a high out-of-pocket cost to the patientas compared to other medications that could provide the same therapeuticeffect for the patient. The clinician's chosen medication may also haveother disadvantages that make proper compliance with the prescriptionadministering difficult. As one example, the chosen medication may haveto be dispensed to a patient multiple times a day, whereas a patientwould prefer a once-a-day dose. The chosen medication may also bedocumented to have caused unwanted side effects in a large segment ofthe population that have taken the medication. In these situations,other medications may be more appropriate to address the specific healthcondition of the patient.

A solution is needed for providing additional options and guidance inmedication selection for a patient that is more tailored to the needs ofthe particular patient.

BRIEF SUMMARY

A system and associated methods provide medication selection guidance atthe time of a prescription event for a given patient, or at other times,such as when changes occur in the patient's healthcare plan coverage. Inone aspect of the invention, a medication selection guidance method fora prescribing event is employed. According to this method, informationis received regarding a clinician-preferred medication prescriptionrelated to a selected patient, and based on at least one record of theselected patient, a specific information set is retrieved. For instance,the specific information set may include medications the patient iscurrently taken, healthcare plan coverage for the patient, or othertypes of information. Then, other medications that can be prescribed tothe patient as alternatives to the clinician-preferred medicationprescription may be determined based on the specific information set.Optionally, an evaluation may be conducted for the alternativemedications against the patient's healthcare plan coverage to presentavailable medication options and associated out-of-pocket costs to thepatient in a report.

Another aspect of the invention includes a method that provides guidancein the selection of medication for a patient. According to the method,information is receive regarding at least one first medication, andbased on at least one record of the selected patient, a specificinformation set is retrieved that includes healthcare plan formularycoverage information for the patient associated with a pricing schedule.Then, therapeutic equivalent medications to the at least one firstmedication are determined based on the healthcare plan formularycoverage information. The therapeutic equivalent medications includemedications that can be administered to the patient as alternatives tothe at least one first medication and which are included in thehealthcare plan formulary coverage information. The therapeuticequivalent medications may be displayed along with information regardinghow the therapeutic equivalent medications fit into the associatedpricing schedule of the healthcare plan formulary coverage information.

In still another aspect of the invention, a method is employed forproviding guidance in the selection of medication for a patient.According to the method, information is received regarding a prescribingevent surrounding at least one first medication, and based on at leastone record of the selected patient, a specific information set isretrieved that includes medications the specific patient is currentlytaking. A drug-drug interaction analysis is performed based on the atleast one first medication and current medications taken by the specificpatient. If a drug-drug interaction match is found between the at leastone first medication and any of the currently taken medications, thenmedications are located that would be therapeutic equivalent medicationsto at least one of the currently taken medications and the at least onefirst medication involved in the match.

Provided in another aspect of the invention is a method for auditingpatient medication costs in response to changes in healthcare plancoverage for the patient. According to the method, information isreceived regarding changes in the healthcare plan of the patient. Morespecifically, the information involves a medication formulary coveragescheme of the healthcare plan. Based on at least one record of thepatient, a specific information set is retrieved that includesmedications the patient is currently taking. Finally, based at least onthe information received regarding a change in the healthcare plan ofthe patient, the cost for medications the patient is currently taking isdetermined utilizing the healthcare plan medication formulary coveragescheme.

BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWING

In the accompanying drawings which form a part of the specification andare to be read in conjunction therewith and in which like referencenumerals are used to indicate like elements in the various views:

FIG. 1 is a block diagram of an exemplary computing system suitable foruse in implementing the present invention;

FIG. 2 is a block diagram of one embodiment of a set of componentmodules of the present invention illustrating the functionalrelationship between the modules;

FIG. 3 is an exemplary report generated by the component modulespresenting the results of a medication selection guidance session;

FIG. 4 is a flow diagram of one method for guiding medication selectionsurrounding a prescribing event;

FIG. 5 is a flow diagram of another method for guiding medicationselection for a particular patient; and

FIG. 6 is a flow diagram of a method for guiding medication selection byauditing patient medication costs in response to changes in healthcareplan coverage for the patient.

DETAILED DESCRIPTION

Systems and methods of the present invention provide improvedefficiencies in guiding medication selection for a given patient by aclinician. For instance, various embodiments are provided fordetermining patient costs for various medication prescription optionsthat may provide a desired therapeutic effect for the patient. Otherembodiments facilitate the auditing of patient medication costs inresponse to changes in healthcare plan coverage for the patient. Theseand other features of the present invention may be further understoodfrom the below description.

General Computing System Environment

FIG. 1 illustrates an example of a suitable computing system environmentin which the invention may be implemented. The computing systemenvironment is only one example of a suitable computing environment andis not intended to suggest any limitation as to the scope of use orfunctionality of the invention. Neither should the computing systemenvironment be interpreted as having any dependency or requirement toany one or combination of components illustrated in the exemplaryoperating environment.

The present invention is operational with numerous other general purposeor special purpose computing system environments or configurations.Examples of well known computing systems, environments, and/orconfigurations that may be suitable for use with the invention include,but are not limited to, personal computers, server computers, hand-heldor laptop devices, cellular telephones, portable wireless devices,multiprocessor systems, microprocessor-based systems, programmableconsumer electronics, network PCs, minicomputers, mainframe computers,distributed computing environments that include any of the above systemsor devices, and the like.

The present invention may be described in the general context ofcomputer-executable instructions, such as program modules, beingexecuted by a computer. Generally, program modules include routines,programs, objects, components, data structures, etc. that performparticular tasks or implement particular abstract data types. Theinvention may also be practiced in distributed computing environmentswhere tasks are performed by remote processing devices that are linkedthrough a communications network. In a distributed computingenvironment, program modules may be located in both local and remotecomputer storage media including memory storage devices.

With reference to FIG. 1, an exemplary system for implementing theinvention includes a general purpose computing device in the form of acomputer system 100. System 100 serves at least in part as a generalmedical information system. Components of system 100 include, but arenot limited to, a processing unit 101, a system memory 102, and a systembus 111 that couples various system components including the systemmemory 102 to the processing unit 101. The system bus 111 may be any ofseveral types of bus structures including a memory bus or memorycontroller, a peripheral bus and a local bus using any of a variety ofbus architecture. By way of example, and not limitation, sucharchitectures include Industry Standard Architecture (ISA) bus, MicroChannel Architecture (MCA) bus, Enhanced ISA (EISA) bus, VideoElectronics Standard Association (VESA) local bus, and PeripheralComponent Interconnect (PCI) bus also known as Mezzanine bus.

System 100 typically includes a variety of computer readable media.Computer readable media can be any available media that can be accessedby system 100 and includes both volatile and nonvolatile media,removable and non-removable media. By way of example, and notlimitation, computer readable media may comprise computer storage mediaand communication media. Computer storage media includes both volatileand nonvolatile, removable and non-removable media implemented in anymethod or technology for storage of information such as computerreadable instructions, data structures, program modules or other data.Computer storage media includes, but is mot limited to, RAM, ROM,EEPROM, flash memory or other memory technology, CD-ROM, digitalversatile disks (DVD) or other optical disk storage, magnetic cassettes,magnetic tape, magnetic disk storage or other magnetic storage devices,or any other medium which can be used to store the desired informationand which can be accessed by system 100. Communications media typicallyembodies computer readable instructions, data structures, programmodules or other data in a modulated data signal such as a carrier waveor other transport mechanism and includes any information deliverymedia. The term “modulated data signal” means a signal that has on ormore of its characteristics set or changed in such a manner as to encodeinformation in the signal. By way of example, and not limitation,communication media includes wired media such as a wired network ordirect wired connection, and wireless media such as acoustic, radiofrequency (RF), infrared and other wireless media. Combinations of anyof the above should also be included within the scope of computerreadable media.

The system memory 102 includes computer storage media in the form of avolatile and/or nonvolatile memory such as read only memory (ROM) 103and random access memory (RAM) 105. A basic input/output system (BIOS)104, containing the basic routines that help to transfer informationbetween elements within system 100, such as during start-up, s typicallystored in ROM 103. RAM 105 typically contains data and/or programmodules that are immediately accessible to and/or presently beingoperated on by processing unit 101. By way of example, and notlimitation, FIG. 1 illustrates operating system 106, applicationprograms 107, other program modules 108, and program data 109.

The system 100 may also include other removable/nonremovable,volatile/nonvolatile computer storage media. By way of example only,FIG. 1 illustrates a hard disk drive 117 that reads from or writes tononremovable, nonvolatile magnetic media, a magnetic disk drive 118 thatreads from or writes to removable, nonvolatile magnetic disk 120, and anoptical disk drive 119 that reads from or writes to a removable,nonvolatile optical disk 121 such as a CD-ROM, DVD-ROM or other opticalmedia. Other removable/nonremovable, volatile/nonvolatile computerstorage media that can be used in the exemplary operating environmentinclude, but are not limited to, magnetic tape cassettes, flash memorycards, digital video disks, digital video tape, Bernoulli cartridges,solid state RAM, solid state ROM, and the like. The hard disk drive 117,magnetic disk drive 118 and optical disk drive 119 are typicallyconnected to the system bus 111 by a Small Computer System Interface(SCSI) 112. Alternatively, the hard disk drive 117, magnetic disk drive118 and optical disk drive 119 may be connected to the system bus 111 bya hard disk drive interface, a magnetic disk drive interface, and anoptical drive interface, respectively.

The drives and their associated computer storage media discussed aboveand illustrated in FIG. 1, provide storage of computer readableinstructions, data structures, program modules and other data for thesystem 100. In FIG. 1, for example, hard disk drive 117 is illustratedas storing operating system 127, application programs 128, other programmodules 129, and program data 130. Note that these components can eitherbe the same as or different from operating system 106, applicationprograms 107, other program modules 108, and program data 109. A usermay enter commands and information into the system 100 through inputdevices such as a keyboard 123 and pointing device 122, commonlyreferred to as a mouse, trackball or touch pad. Other input devices (notshown) may include a microphone, joystick, game pad, satellite dish,scanner, or the like. These and other input devices are often connectedto the processing unit 101 through a user input interface 113 or aserial port interface 114 that is coupled to the system bus 111, but maybe connected by other interface and bus structures, such as a parallelport, game port or a universal serial bus (USB). A monitor 116 or othertype of display device is also connected to the system bus 111 via aninterface, such as a video adapter 110. In addition to the monitor 116,computers may also include other peripheral output devices such asspeakers and printers, which may be connected through an outputperipheral interface.

The system 100 may operate in a networked environment using logicalconnections to one or more remote computers, such as a remote computer133 and/or other electronic devices, such as a communication device 132.The remote computer 133 may be a personal computer, a server, a router,a network PC, a peer device or other common network node, and typicallyincludes many or all of the elements described above relative to thesystem 100, although only a memory storage device has been illustratedin FIG. 1. Remote computer 133 may, for example, be found at a varietyof health system related locations, such as hospitals, other inpatientsettings, pharmacies, a clinician's office/practice, ambulatorysettings, testing labs and a patient's home environment, though otherlocations may be chosen as well. The communication device 132 may be amobile cellular phone, mobile text-pager or other portablecommunications device, and typically includes some of the elementsdescribed above relative to the system 100. The logical connectionsdepicted in FIG. 1 include a local area network (LAN) 126 and a widearea network (WAN) 125, but may also include other networks. Suchnetworking environments are commonplace in offices, enterprise-widecomputer networks, intranets and the Internet.

When used in a LAN networking environment, the system 100 may beconnected to the LAN 126 through a networking interface or adapter 115.When used in a WAN networking environment, the system 100 typicallyincludes a modem 124 or other means for establishing communications overthe WAN 125, such as the Internet. The modem 124, which may be internalor external, may be connected to the system bus 111 via the serial portinterface 114 or other appropriate mechanism. In a networkedenvironment, program modules depicted relative to the system 100, orportions thereof, may be stored in the remote storage device. By way ofexample, and not limitation, FIG. 1 illustrates remote applicationprograms 131 as residing on memory devices 132 and 133. It will beappreciated that the network connections shown are exemplary and othermeans of establishing a communications link between the computers and/orportable communication devices may be used.

Although many other internal components of the system 100 are not shown,those of ordinary skill in the art will appreciate that such componentsand the interconnection are well known. Accordingly, additional detailsconcerning the internal construction of the system 100 need not bedisclosed in connection with the present invention.

Those skilled in the art will understand that program modules such asthe operating system 106 and 127, application programs 107 and 128, andprogram data 109 and 130 are provided to the system 100 via one of itsmemory storage devices, which may include ROM 103, RAM 105, hard diskdrive 117, magnetic disk drive 118 or optical disk drive 119.Preferably, the hard disk drive 117 is used to store program data 130and 109, application programs 107 and 128, and operating system 106 and127.

When the system 100 is turned on or reset, the BIOS 104, which is storedin the ROM 103 instructs the processing unit 101 to load the operatingsystem from the hard disk drive 117 into the RAM 105. Once the operatingsystem 127 is loaded in RAM 105, the processing unit 101 executes theoperating system code and causes the visual elements associated with theuser interface of the operating system 127 to be displayed on themonitor 116 or other display device. When an application program 107 and128 is opened by a user, the program code and relevant data are readfrom the hard disk drive 117 and stored in RAM 105.

Medication Selection Guidance

Illustrated in FIG. 2 is the general flow of activity through a set ofgeneral component modules 200 functioning within the system 100. Throughthe utilization of the general component modules 200, guidance isprovided in selecting, for a patient, medications that possess a desiredtherapeutic effect.

Various terminology discussed with respect to the present invention mayhave particular meaning as described below. For instance, the term“clinician” includes, but is not limited to, a treating physician,specialists such as surgeons, radiologists and cardiologists, emergencymedical technicians, physician's assistants, nurse practitioners,nurses, physical therapists, pharmacists, dieticians, microbiologists,and the like, and aides or assistants thereto. The term “patient” refersto a person that is receiving or has received health-care-relatedservices, including medication prescription services, in any location ina medical environment (e.g., hospitals or other inpatient or outpatientsettings, a clinician's office/practice location, ambulatory settings,testing labs, patient's home environment, or in any other setting, suchas over a remote network or the Internet). The component modules 200 mayinteract with various types of informational databases containingcertain types of general medical information, as well as interactingwith medical records that contain information about specific patients.As an example, these medical records may take the form of an electronicmedical record (EMR) for a particular patient. The electronic medicalrecord is typically designed to contain various types of data about anindividual patient, such as: patient identifying information; insuranceand financial information; patient health status, such as observedconditions of the patient, medications taken and current immunizations,food allergies, drug (i.e., medication) allergies, diagnoses of variousclinicians; and care documentation including a listing of cliniciansthat are currently providing or that have provided care to the patient.As one example, the EMR may take the form of a continuity of care record(CCR), and may include a personal health record (PHR) maintained by aparticular patient. It should be understood, however, that the term“medical record”, “patient record” or “electronic medical record” inparticular, should not be interpreted to be limited to any type ofcomputer-readable format or record, but includes anyelectronically-stored data structure containing information relative toat least one specific patient. The term “healthcare entity” is meant todenote any organization or institution forming a healthcare deliverysystem or network, or any subcomponents thereof functioning individuallyor collectively with other subcomponents (e.g., health system relatedlocations such as hospitals or medical offices, individual providerssuch as clinician or group practices, among others).

With specific reference to FIG. 2, component modules 200 includes a dataretrieval component 202 that requests and accepts various forms of dataor information relating to particular patients and medications, a dataanalysis component 204 that takes the accepted data from data retrievalcomponent 202 and performs certain analysis of the data, and a reportingcomponent 206 that presents the results of the data evaluations by dataanalysis component 204 so that a clinician may prescribe appropriatemedications that meet the particular patient's needs. More specifically,component modules 200 may take into account a variety of factors thatinfluence medication delivery, including, in one embodiment, drugutilization review (DUR) checking and administrative utilization review(AUR) checking. These DUR and AUR checking schemes also look to personalhealth information about a specific patient, such as the patient'shealth-related conditions and healthcare plan coverage information.Component modules 200 utilize the above-mentioned factors andinformation to optimize the evaluation process of multiple medicationsto ensure that an acceptable efficacy profile is maintained while alsoachieving a result that is preferable to the patient. For instance, apatient in need of a given therapeutic effect may be provided with aselected medication delivering the necessary effect at a more attractiveout-of-pocket cost than a clinician might have otherwise provided. Theselected medication may be revealed to the clinician through utilizationof the present invention, ensuring that high-quality solutions areprovided that achieve the same therapeutic outcome as the cliniciandesired.

Data retrieval component 202 gathers patient and medication-relatedinformation (including information needed for drug utilization reviewand administrative utilization review checking) from a variety of datasources. These data sources may include databases, such as clinicalknowledge bases containing various medical knowledge, as well as patientmedical records and the like. Data sources may be located remotely fromdata retrieval component 202 and retrieved, for example, over any typeof electronic network.

For a given patient, medical records and other sources may be queried bydata retrieval component 202 to determine personal health information,including the medications that the patient is documented to bereceiving, the patient's allergies to medications, and healthcare plancoverage information for the patient. The healthcare plan may be aconventional health insurance plan providing a certain amount ofmedication cost coverage, or may take the form of another medicationplan that providing similar coverage or medication discounts. In eithercase, the entity offering the healthcare plan is referred to as a“provider” herein. Healthcare plan information preferably includes amedication formulary, which documents medications the healthcare planprovider would at least partially cover at a fixed or variable cost tothe patient. The medication formulary indicates specific coveragethrough a pricing schedule. One example of a pricing schedule is atiered structure, where each tier provides a different level ofcoverage. For instance, the tiers may take the form shown in Table 1,each having a different cost to the patient.

TABLE 1 Tier 1 Generic Drug Coverage $5 Co-pay Tier 2 Preferred DrugBrand Coverage $10 Co-pay Tier 3 Non-Preferred Drug Brand Coverage $25Co-pay plus %10 of Retail Price Tier 4 Coverage for Drugs that have a$50 Co-pay plus %10 Generic Equivalent of Retail PriceHealthcare plan coverage may be extended to over-the-counter (OTC)medications, depending on provider preferences.

Drug utilization review checking and administrative utilization reviewchecking may be conducted, in various embodiments, for proposedmedications to be prescribed to a patient and/or medications currentlytaken by the patient according to their medical records. Drugutilization content is retrieved through a query of electronicallysearchable clinical knowledge databases (e.g., the MULTUM databaseoffered by Cerner Multum, Inc.). Other sources of drug utilizationcontent may also be queried. The drug utilization content is used bydata analysis component 204 to perform, for instance, adverse drugreaction (ADR) determinations, such as drug-drug interactions anddrug-allergy reactions of the particular patient based on informationextracted from the patient's medical records. Thus, DUR checking enablesthe elimination of certain medications from consideration.Administrative utilization review checking is concerned with providingthe patient more cost effective medication options while minimizingmedication delivery complexity. AUR checking may look to the patient'scurrently taken medications, therapeutic alternatives related to healthconditions (e.g., diseases) of the patient, the patient's healthcareplan medication formulary, and compliance complexity and fulfillmentoption information for medication options.

Therapeutic alternative content designates medication classes that areknown to provide a given therapeutic effect, or a “therapeuticequivalency”. For instance, these medication classes may be determinedby chemical equivalency (i.e., medications within the class having thesame active ingredient, such as generics), disease-specific therapeuticequivalency (i.e., for a given disease, medications within the classprovide essentially the same desirable treatment or therapeutic effect)and/or evidence-based therapeutic equivalency (i.e., a trusted knowledgesource determines that medical evidence shows the efficacy of usingmedications within the class to treat a certain health condition).Acceptable sources of therapeutic alternative content may begovernmental and/or regulatory bodies, as well as overseeing healthcareentities. One exemplary source for therapeutic alternative content isthe Food and Drug Administration's (FDA) “Approved Drug Products withTherapeutic Equivalence Evaluations”, also known as the “Orange Book”.

Compliance complexity content provides an indication of burdens tomedication administration to patients, and thus, the degree ofdifficulty in getting the patient to comply with the clinician'stherapeutic treatment plan. Exemplary compliance complexity contentincludes the number and types of dosage requirements for a givenmedication (e.g., for adults, medication taken in liquid drops threetimes a day for treatment of a specific health condition), and sideeffects that have been observed in some patients. Fulfillment optionsinclude modes of delivering medications to patients from one or moresuppliers (i.e. prescription fillers), as well as associated pricingdata for each mode. Exemplary delivery modes include mail-order andretail store, but other modes may be employed.

Activity of the data analysis component 204 will now be described infurther detail. Data analysis component 204 receives the informationrelating to particular patients and medications that is relevant to thedrug utilization review and administrative utilization review checking,and performs an analysis to optimize the presentation of medicationoptions for the patient.

For drug utilization review checking, the patient's documentedhealth-related conditions (e.g., currently taken medications andallergies to specific medications) and/or proposed medications for agiven health condition are compared to the drug utilization content todetermine if adverse drug-drug interactions or drug-allergy reactionsmay occur. Proposed medications for a given health condition mayinclude: (1) a clinician-preferred medication or a set of medications;and (2) therapeutic equivalent medications to the clinician-preferredmedication(s).

Administrative utilization review checking, in one embodiment, firstinvolves a determination of therapeutic equivalent alternatives(“therapeutic equivalents”) to the clinician-preferred medication(s) ormedications currently taken by the patient utilizing the therapeuticalternative content. Therapeutic equivalents may be requested in avariety of circumstances. One such circumstance is when the drugutilization review checking reveals an adverse drug reactions match.However, therapeutic equivalents may also be requested prior toperforming the drug utilization review checking so that such equivalentsare run through the DUR checking. Furthermore, therapeutic equivalentrequesting may be conducted even if no drug utilization review isundertaken because therapeutic equivalent medications may still providea more cost effective and/or simpler compliance regime than currentlytaken medications or clinician-preferred medication(s). Upon assemblinga list of therapeutic equivalents, another evaluation is made regardingwhether the patient's healthcare plan medication formulary includesmedications that match with any of the list of therapeutic equivalents,and for each match, determining where the medication fits within theformulary pricing schedule. For each formulary medication match, as wellas the proposed clinician-preferred medication(s) or medicationscurrently taken by the patient—collectively the “medication options”—acompliance complexity evaluation is performed to provide informationabout burdens to the patient of administering the medication options. Acompliance complexity score may also be provided for each medicationoption to characterize how difficult compliance may be for a typicalpatient. A once-a-day administration of a medication, for example, wouldreceive a lower complexity score than the same or therapeuticallyequivalent medication that needs to be administered multiple times a dayfor proper efficacy. Thus, a lower compliance complexity score is apreferred score. Fulfillment options may also be evaluated for each ofthe medication options. As an example, if the patient has an acuteillness that requires a short antibiotic regimen, it would not makesense for them to acquire their medication through mail-order channels.In this case, a mail-order option would be excluded as an optionalmedication choice. The fulfillment option evaluation may also includecorrelating fulfillment option information with a patient's healthcareplan medication formulary pricing schedule. In this way, a given mode ofprescription fulfillment from specific suppliers will be associated withan out-of-pocket cost to the patient. Furthermore, if medication optionsevaluated for compliance complexity represent a different cost, becauseof the fulfillment choices and/or the healthcare plan medicationformulary pricing schedule (e.g., the once-a-day dosage costs $40out-of-pocket for one prescription fill and the regular multi-dose cost$20 out-of-pocket for the same prescription fill), this cost informationis noted. Administrative utilization review checking may also allow aclinician or healthcare entity to input certain exception data into thedata analysis component 204 (or to retrieve such exception data from adata source). This exception data may limit certain classes of patients(or specific patients through information in their medical record) fromreceiving medications or receiving medications through a mode that wouldprovide excessive compliance complexity. As one example, an exceptiondata set may require that children only receive a prescription forRitalin that is a once-a-day dose, so that parents can more closelymonitor the administration of the medication. Other exemplary exceptiondata may include gender-based data, step-care requirements (e.g.,prescribe medication A to determine if it is effective prior toprescribing medication B), prior authorization requirements (e.g.,clinician prescribing must get approval from a superior clinician in thehealthcare entity), among others. Exception data may be set by thehealthcare entity in which the clinician is practicing, by thehealthcare plan provider, or other entities.

Upon completion of the drug utilization review and administrativeutilization review analysis, the data analysis component 204communicates the results to the reporting component 206 so that a reportof the analysis may be compiled and presented to the clinician and/orthe patient for review. It should be understood that a “report” may bein any kind of format or configuration, including any type of layout ofinformation, and may be embodied in an electronic or hard copy form. Oneexemplary report 300 depicted in FIG. 3 takes the form of an electronicreport including actionable indicators 302 for selection and/or deletionof particular medications from a list of potential medications that maybe ordered. For the patient's current prescription regimen, includingclinician-preferred Drugs A and B, data analysis component 204determines (through information provided by data retrieval component202) that certain alternative medications provide the same therapeuticeffect as the combination of Drugs A and B, but with a lowerout-of-pocket cost to the patient, as well as a lower compliancecomplexity. These alternative medications that can substitute for thecombination of Drugs A and B are: Drug C; Drug D; or the combination ofDrugs E and F. Drugs E and F are generics of Drugs A and B,respectively. Drug D is a provides an even lower compliance complexityranking that Drug C, but because it is a once-a-day time release dose,Drug D is provided at a cost that is higher than Drug C, but still lowerthan the clinician-preferred combination of Drugs A and B. Each mode ofprescription fulfillment for each medication option listed, Drugs A andB, Drug C, Drug D, and Drugs E and F, has an associated hyperlink 304 orsimilar data link for selection of a particular medication option andfulfillment mode. Upon selection of one of the hyperlinks 304, acommunication is transmitted (e.g., an email transmission or othermessaging means) to the associated prescription filling entityinstructing the entity to fill the associated prescription.

The report 300 shown may be generated by the clinician during aprescribing event, or at other times. In one embodiment, report 300 isgenerated to determine if there are other cheaper, therapeuticallyequivalent medications that could be taken instead of a currentmedication regimen. Upon invoking component modules 200, data analysiscomponent 204 evaluates the medication options and presents them throughthe electronic report 300. If the review is being done by the patient,then, upon selection of a particular mode of prescription fulfillment, acommunication is transmitted to the patient's clinician designating thepatients preferred medication option and presenting the overall reportto the clinician. The clinician may agree with the patient's medicationselection and choose to prescribe the chosen medication instead of thecurrent medication regimen. Alternatively, the clinician may decide thatanother medication selection would be better for the patient based onthe results contained in the report 300.

Additionally, the report 300 may be provided with a means for enteringdata, such as textbox 306, so that additional medication options may berequested in addition to those presented. For instance, if each of themedication options has a compliance complexity score that isuncomfortably high for the prescribing clinician and/or the patient, arequest may be made on the report 300 to search for additionaltherapeutic equivalent medications to the medication options provided.Although such additional therapeutic equivalents may require a higherout-of-pocket cost, for example, the patient may be more satisfied withthe result and have a better chance of maintaining compliance with theclinician's treatment plan. Furthermore, it should be noted that thecomponent modules 200 may be guided by various rules so that less than acertain number of medication options are made available so as to notoverwhelm the user who will be studying the report 300. For example, ifmore than one therapeutic equivalent medication is available within agiven tier of the patient's healthcare plan medication formulary, thenthe medication with the lowest out-of-pocket cost to the patient acrossthe various fulfillment options may be presented, and the remainingmedications within the tier are eliminated from consideration (or areonly later presented if others are deleted from the report).

Various methods utilizing the functionality of component modules 200 ofthe present invention are shown in FIGS. 4-6. With particular referenceto FIG. 4, one method 400 for performing medication selection guidancesession for a particular patient surrounding a prescribing event isdepicted. A clinician first selects for prescription a medicationpreference (or set of medications depending on therapeutic treatmentprotocols) for treatment of a specific health condition that has beendiagnosed in the patient, in step 402. The prescription may be aninitial prescription event or a refill of an ongoing prescription.Retrieval of various types of information, including health informationpersonal to the patient and medication-related information, then occursin step 404 through data retrieval component 202. For instance, theretrieved information can include: health-related conditions andhealthcare plan information for the patient from their medical record;therapeutic alternative content related to the clinician-preferredmedication; and for each of the medication options (i.e., theclinician-preferred medication and the therapeutic equivalentmedications to the preferred medication), drug utilization reviewcontent, compliance complexity content and fulfillment options. Adetermination is made in step 406 by data analysis component 204 as towhether any of the medication options would cause a drug-druginteraction or allergic reaction for the patient based on a drugutilization check. If one of the medications would cause such adrug-drug interaction or allergic reaction of a sufficient severity,then in step 430 each of the problem medications is eliminated fromconsideration. Conversely, for each of the medication options that wouldnot cause a drug-drug interaction or allergic reaction of a sufficientseverity, another determination is made in step 408 by data analysiscomponent 204 as to whether each of the remaining medications are withinthe healthcare plan medication formulary. If a specific medication isnot within the formulary, then it may be eliminated from considerationin step 430. On the other hand, if a specific medication is found to bewithin the formulary, then the location of the medication option withinthe pricing schedule or specific tier is determined by data analysiscomponent 204 in step 410.

Continuing with step 412, data analysis component 204 evaluates thecompliance complexity for the remaining medications options within theformulary. Optionally, the evaluation may include assigning a compliancecomplexity score to the medication based on a certain metric (e.g.,frequency of dosage required, frequency and intensity of side effects,etc.). Additionally, for such remaining medication options, fulfillmentoptions are evaluated by data analysis component 204 in step 414 todetermine which modes of filling a prescription (and which prescriptionfillers/suppliers) are available. In step 416, for each of theprescription filling modes and supplier options, data analysis component204 makes a correlation with the patient's healthcare plan medicationformulary pricing schedule, so that out-of-pocket costs to the patientfor each option are determined. Another optional step 418 may beimplemented regarding exception data, so that certain medications andmedication fulfillment modes may be restricted for certain patientclasses by data analysis component 204. Finally, in step 420, a reportis generated by reporting component 206 presenting the remainingmedication options for selection, including pricing information forvarious fulfillment modes and compliance complexity scores.

Another method 500 for guiding medication selection for a particularpatient is illustrated in FIG. 5. In step 502 of the method 500,information is received by the component modules 200 regarding a recentprescribing event. Component modules 200 may poll various patientrecords for the information, or it may be automatically compiled and setto the component modules 200 by another entity networked with themodules. The information may include details about a specific medicationprescription and other related information. Upon learning of theprescribing event, health-related condition information for thepatient—specifically, medications the patient is currently taking otherthan the medication prescription from the recent prescribing event—isretrieved from the patient's medical record in step 504 through dataretrieval component 202. A determination is made in step 506 by dataanalysis component 204 as to whether the medications the patient istaking would cause a drug-drug interaction with the recent medicationprescription based on a drug utilization check. If no drug-druginteraction would result, then the method reaches an endpoint.Conversely, if a drug-drug interaction would result, then in step 508various types of information are retrieved through data retrievalcomponent 202, including healthcare plan information for the patient,therapeutic alternative content related to at least one of themedications involved in the drug-drug interaction, compliance complexitycontent and fulfillment options.

Continuing with step 510, another determination is made by data analysiscomponent 204 as to whether therapeutic equivalents to at least one ofthe medications involved in the drug-drug interaction would cause adrug-drug interaction with any remaining medications being taken by thepatient. For each therapeutic equivalent medication causing a drug-druginteraction, the respective therapeutic equivalent is eliminated fromconsideration in step 530. For therapeutic equivalent medications thatwould not cause a drug-drug interaction (i.e., acceptable therapeuticequivalents), a determination is made by data analysis component 204 instep 512 as to whether such medications are within the healthcare planmedication formulary for the patient. If any acceptable therapeuticequivalent is not within the formulary, then it may be eliminated fromconsideration in step 530. On the other hand, for each acceptabletherapeutic equivalent medication that is within the formulary, then thelocation of the medication within the pricing schedule or specific tieris determined by data analysis component 204 in step 514. Next, dataanalysis component 204 evaluates the compliance complexity for eachacceptable therapeutic equivalent medication in step 516. Fulfillmentoptions are then evaluated by data analysis component 204 in step 518for each acceptable therapeutic equivalent medication. Utilizing thefulfillment options and the patient's healthcare plan medicationformulary pricing schedule, in step 520, data analysis component 204determines out-of-pocket costs to the patient for each option. Finally,in step 522, a report is generated by reporting component 206 presentingthe acceptable therapeutic equivalent medication for selection,including pricing information for various fulfillment modes andcompliance complexity scores.

Auditing of patient medication costs in response to changes inhealthcare plan coverage for a specific patient is achieved throughmethod 600 depicted in FIG. 6. Information is received by the componentmodules 200 in step 602 regarding changes in the medication formularypricing schedule for a patient's healthcare plan. Similar to the method500 of FIG. 5, component modules 200 may poll various patient recordsfor the information, or it may be automatically compiled and set to thecomponent modules 200 by another entity networked with the modules. Uponreceiving the medication formulary change information, in step 604,various patient and medication-related information is retrieved throughdata retrieval component 202. The retrieved information may include: thepatient's health-related conditions and healthcare plan information fromthe medical record; therapeutic alternative content related to currentlytaken medications; and for each of the medication options (i.e.,currently taken medications and therapeutically equivalent medicationsto the currently taken medications) drug utilization review content,compliance complexity content and fulfillment options.

Continuing with step 606, a determination is made by data analysiscomponent 204 as to whether any of the therapeutically equivalentmedications would cause an allergic reaction for the patient based ontheir health-relation condition information and a drug utilizationcheck. For each therapeutic equivalent medication causing an allergicreaction, the respective therapeutic equivalent is eliminated fromconsideration in step 630. For therapeutic equivalent medications thatwould not cause an allergic reaction (i.e., acceptable therapeuticequivalents), a determination is made by data analysis component 204 instep 608 as to whether such medications are within the healthcare planmedication formulary for the patient. If any acceptable therapeuticequivalent is not within the formulary, then it may be eliminated fromconsideration in step 630. On the other hand, for each acceptabletherapeutic equivalent medication that is within the formulary, then thelocation of the medication within the pricing schedule or specific tieris determined in step 610 by data analysis component 204. Next, dataanalysis component 204 evaluates the compliance complexity in step 612for each acceptable therapeutic equivalent medication. Fulfillmentoptions are then evaluated by data analysis component 204 for eachacceptable therapeutic equivalent medication, in step 614. Utilizing thefulfillment options and the patient's healthcare plan medicationformulary pricing schedule, out-of-pocket costs to the patient for eachoption are determined by data analysis component 204 in step 616.Finally, in step 618, a report is generated by reporting component 206presenting the acceptable therapeutic equivalent medication forselection, including pricing information for various fulfillment modesand compliance complexity scores.

It can be seen, therefore, that the system and methods of the presentinvention provide improved medication selection guidance so that a costeffective and therapeutically-sound medication regime may be obtainedfor a patient having a certain healthcare plan. Furthermore, sincecertain changes may be made in the above system and methods withoutdeparting from the scope hereof, it is intended that all mattercontained in the above description or shown in the accompanying drawingsbe interpreted as illustrative and not in a limiting sense.

1. A method in a computer system for auditing patient medication costsin response to changes in healthcare plan coverage for the patient,comprising: receiving information regarding changes in the healthcareplan of the patient, the information involving a medication formularycoverage scheme of the healthcare plan; retrieving a specificinformation set based on at least one record of the patient, theinformation set including medications the patient is currently taking;and based at least on the information received regarding a change in thehealthcare plan of the patient, determining patient costs formedications the patient is currently taking utilizing the healthcareplan medication formulary coverage scheme.
 2. The method of claim 1,further comprising: determining therapeutic equivalent medications tothe currently taken medications.
 3. The method of claim 2, wherein thespecific information set includes known allergies of the patient, themethod further comprising: for the therapeutic equivalent medications,performing a drug-allergy reaction analysis based on known allergies ofthe specific patient.
 4. The method of claim 2, further comprising:evaluating fulfillment options for the therapeutic equivalentmedications; and determining patient costs for the therapeuticequivalent medications utilizing the healthcare plan medicationformulary coverage scheme for each of the fulfillment options.